Elsevier

Journal of Nuclear Cardiology

Volume 20, Issue 6, December 2013, Pages 1118-1143
Journal of Nuclear Cardiology

An ASNC 20th Anniversary Article
Gated SPECT in assessment of regional and global left ventricular function: An update

https://doi.org/10.1007/s12350-013-9792-1Get rights and content

Abstract

Gated myocardial perfusion SPECT (GSPECT) is a major clinical tool, widely used for performing myocardial perfusion imaging procedures. In this review, we have presented the fundamentals of GSPECT and the ways in which the functional measurements it provides have contributed to the emergence of myocardial perfusion SPECT in its important role as a major tool of modern cardiac imaging. GSPECT imaging has shown unique capability to provide accurate, reproducible and operator-independent quantitative data regarding myocardial perfusion, global and regional systolic and diastolic function, stress-induced regional wall-motion abnormalities, ancillary markers of severe and extensive disease, left ventricular geometry and mass, as well as the presence and extent of myocardial scar and viability. Adding functional data to perfusion provides an effective means of increasing both diagnostic accuracy and reader’s confidence in the interpretation of the results of perfusion scans. Assessment of global and regional LV function has improved the prognostic power of myocardial perfusion SPECT and has been shown in a large registry to add to the perfusion assessment in predicting benefit from revascularization.

Introduction

Over the last few decades, the assessment of myocardial perfusion from stress and rest myocardial perfusion SPECT has become one of the most reliable clinical tools in the management of patients with known or suspected coronary artery disease (CAD).1 ECG-gated SPECT, with the ability to measure LVEF and ventricular volumes as well as to evaluate presence of regional wall motion abnormalities (RWMA), has become a routine part of clinical protocols, expanding the clinical utility of myocardial perfusion SPECT. ACC/AHA/ASNC guidelines for the clinical use of cardiac radionuclide imaging consider ECG-gated SPECT as “…the current state of the art… The ability to observe myocardial contraction in segments with apparent fixed perfusion defects permits the nuclear test reader to discern attenuation artifacts from true perfusion abnormalities. The ability of gated SPECT to provide measurement of left ventricular (LV) EF (LVEF), segmental wall motion, and absolute LV volumes also adds to the prognostic information that can be derived from a SPECT study.”2 Most recent (2012) multisociety guidelines for the diagnosis and management of patients with stable ischemic heart disease support Class I and Class IIA recommendations for diagnostic use of Gated SPECT in majority of symptomatic patients with known or suspected CAD, and indeterminate or higher likelihood of either obstructive CAD (in case of no prior history of CAD) or ischemia (in case of known prior CAD).3

Gated SPECT (G-SPECT) is now performed in nearly all myocardial perfusion SPECT studies in the United States4 and other countries.5, 6, 7, 8 The strong appeal of GSPECT imaging is a direct consequence of the ease and modest expense with which perfusion assessment is “upgraded” to include function assessment, and accounts for its becoming a routine part of myocardial perfusion SPECT (MPS) studies (Figure 1).9 The significant temporal trend toward increase in proportion of MPS studies being performed as G-SPECT (Figure 2) has been seen globally over in the last decade.5

This review is intended to describe the major milestones in which ventricular function assessment has emerged and added to perfusion assessment using gated SPECT. Compared to our original 2006 JNC paper,10 we updated and added new references and figures describing most recent developments of the hardware and software utilized in the G-SPECT acquisition and interpretation, and added important references advancing our understanding of potential clinical implications of the functional assessment using the G-SPECT methodology. New findings relating to perfusion parameters from myocardial perfusion SPECT are not covered in this review, and may be found in other recent reviews.11

Section snippets

Technical Milestones

The era of modern clinical nuclear cardiology began in the late 1960s with the introduction of the Anger scintillation camera, which was able to provide dynamic images of the cardiac distribution of radioactivity. Early in the 1970s, the ability to accurately assess ventricular function noninvasively, initially with end-systolic and end-diastolic equilibrium radionuclide ventriculography and the use of an ECG-gating device,12 and shortly thereafter with early medical imaging computers, led to

Combined Rest/Post-Stress Regional Function Analysis

Modern computer software allows side-by-side comparison of the rest and post-stress gated images to identify the development of new wall motion abnormality; this comparison becomes even more effective with new workstations’ dual-monitor displays. Wall motion abnormalities that occur on post-stress images but are not seen on resting images imply the presence of ventricular stunning, and are highly specific for the presence of coronary artery disease.56105,106 Moreover, even if resting GSPECT

Reproducibility of Global and Regional Quantitative Function Measurements

The published results concerning the reproducibility and repeatability of measurements of quantitative function parameters from gated perfusion SPECT for commercially available algorithms demonstrate very good to excellent agreement between independent measurements.17,18,25,55,82,91,93, 94, 95,97,99,111,119,132,152, 153, 154,165, 166, 167, 168, 169, 170, 171, 172, 173, 174 Even semi-automatic algorithms that require minor operator intervention (slice selection, manual isolation of the LV,

Stunning

Johnson et al first reported in 1997 that of 61 patients with reversible ischemia imaged using a 2-day, treadmill stress and rest gated 99mTc-sestamibi SPECT protocol, 22 (36%) had significantly lower post-stress LVEF compared to the rest LVEF.47 The threshold of ±5.2% (2 SD) for statistically significant differences had been determined from a separate group of 15 patients undergoing serial rest gated SPECT on consecutive days. The authors attributed the reduction in LVEF in those 22 patients

Transient Ischemic Dilation Ratio

TID of the left ventricle was first described for the epicardial borders of stress/redistribution planar 201Tl studies.211 In the era of GSPECT, the same software that was used for defining the edges of the left ventricle for purposes of assessing ventricular function was applied for the automatic measurement of TID using SPECT. The TID ratio is calculated as a ratio of the ungated LV cavity volume post-stress and at rest. The TID ratio measured by SPECT may reflect true stress-induced stunning

LV Shape

The LV can be reasonably approximated by an ellipsoid,17 and consequently it is easy to estimate its shape using the major and minor axes of the ellipsoid that best fits it. The closer the axes in size, the closer the ellipsoid becomes to a sphere, a case consistent with LV remodeling associated with congestive heart failure or other pathologies. A potentially more accurate algorithm for shape assessment has also been proposed that is based on the regional search for the maximal distance

LV Dyssynchrony

In the very early years of the clinical nuclear cardiology, the ability of gated scintigraphy—at the time blood pool imaging—to assess left ventricular dyssynchrony was described. Over the last several years, the assessment of dynsynchrony by GSPECT has been extensively validated and studied for its clinical applications. Multiple studies using different software packages have shown that the degree of LV dyssynchrony seen on GSPECT can predict response to cardiac resynchronization therapy

Integration of GSPECT in Diagnostic Work-Up of Patients with Suspected CAD

According to current guidelines,2 the consideration of using a stress imaging study is preceded by assessment of the pretest likelihood of CAD, using Bayesian analyses of patient age, sex, risk factors, and symptoms, as initially developed by Diamond and colleagues.222, 223, 224

As it is shown in the proposed clinical algorithm of management of patients with suspected CAD (Figure 12), those who clinically are classified as low-likelihood (<15%) patients do not need stress testing at all. They

Definition of Normal GSPECT Study: Consideration of Clinical Data, Perfusion, and Function Parameters

Recently, we proposed a specific algorithm defining diagnostic certainty of the gated SPECT study interpretation.226 It takes in consideration multiple perfusion and nonperfusion parameters and may have implications for the expected outcome. In this regard, one may define a perfectly normal study as: (1) perfectly normal rest and post-stress perfusion; (2) normal rest (optional) and post-stress global and regional systolic function; (3) normal or small (either visual or quantified) LV volumes

Added Value of Gated SPECT in Clinical Risk Stratification

Assessment of ventricular function variables from GSPECT has added to perfusion assessments in clinical risk stratification. One form in which this has become apparent is seen in the manner in which gated function studies have improved the identification of patients with severe and extensive CAD. This was mentioned in part by noting the added value of TID assessment above, an automated measurement that is an off-shoot of the methods used for assessing ventricular function. Evidence that the

Gated SPECT for Predicting Benefit from Revascularization

Beyond risk-stratification, optimal selection of patient treatment is based on reasonable estimates of potential patient benefit with one treatment option versus an alternative. Factors such as LV ejection fraction and the size of prior myocardial infarction are known to be predictive of risk in the patient with CAD. However, assessment of CAD risk and prediction of benefit from revascularization are very different. To this end, ischemia on MPI may allow identification of patients who may

Conclusion

Gated myocardial perfusion SPECT is a major clinical tool widely used for performing myocardial perfusion imaging procedures. In this review, we have presented the fundamentals of GSPECT and the ways in which the functional measurements it provides have contributed to the emergence of myocardial perfusion SPECT in its important role as a major tool of modern cardiac imaging. We conclude that GSPECT imaging has shown unique capability to provide accurate, reproducible and operator-independent

Acknowledgements

Some of the research described in this review was supported in part by Grant R01-HL089765 from the National Heart, Lung, and Blood Institute/National Institutes of Health (NHLBI/NIH). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the NHLBI.

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